12. Complete the following concerning platelets:

G7 p.34:165mm

a. Normal platelet count is_____to _____.

150 k to 400 k/mm³

b. Delay surgery if platelets are below _____.

50,000/mm³

c. Transfuse if:

     i. surgery is_____

urgent

     ii. patient is on_____ or_____and can’t wait_____days.

Plavix or ASA 5 to 7

d. Usual transfusion is_____of platelets.

an eight-pack (= 6 to 10 U)

e. One U raises platelets by_____.

10k

13. Complete the following regarding platelet therapy:

G7 p.35:20mm

a. 1 unit of platelets has a volume of approximately_____cc.

50

b. Platelet count can be checked in _____hours.

2

c. Re-transfusion will be needed in_____days.

3 to 5

G7 p.35:120mm

14. Complete the following concerning fresh frozen plasma:

G7 p.35:130mm

a. One bag equals_____cc.

250

b. Risk of acquired immunodeficiency syndrome (AIDS) or hepatitis is the same as_____.

a unit of blood

c. Use to reverse Coumadin:

     i. prothrombin time (PT) greater than_____

18 seconds

     ii. international normalized ratio (INR) greater than_____

1.6

     iii. von Willebrand disease unresponsive to_____

DDAVP

     iv. multiple coagulation dysfunction such as in

          h_____ _____

hepatic dysfunction

          v_____ _____ _____

vitamin K deficiency

          D_____

DIC

15. In regard to the use of anticoagulation in a patient who has:

G7 p.37:60mm

a. An incidental aneurysm < 4mm, anticoagulation is_____

ok

b. A drug eluting cardiac stent—continue_____

Plavix

c. At onset of SAH we should_____anticoagulation

reverse

d. Postoperative craniotomy may start on day_____ to_____weeks after surgery

3 to 5

16. In regard to anticoagulation in preparation for surgery, if a patient has:

G7 p.37:145mm

a. mechanical heart valve

     i. stop warfarin_____days before surgery

3

     ii. and use_____

Lovenox

b. chronic A-fib

     i. stop warfarin_____days before surgery

4 to 5

17. Complete the following concerning anticoagulation:

G7 p.37:167mm

a. May resume anticoagulation_____ days after craniotomy

3 to 5

b. Annual risk of nonanticoagulation for a patient with

     i. mechanical heart valve is _____% per year

6%

     ii. chronic atrial fibrillation is _____% per year

4 to 6%

c. If patient is on Plavix or acetylsalicylic acid (ASA) delay surgery for_____.

5 to 7 days

18. Provide coagulation factors for neurosurgery.

G7 p.38:20mm

a. PT should be below_____seconds.

13.5

b. INR should not be above_____.

1.4

c. For emergencies give_____ _____units

FFP2

d. and_____ _____.

vitamin K

19. Both Plavix and ASA inhibit platelet function for how long?

permanently

G7 p.38:90mm

20. Plavix is a more dangerous drug than ASA because it remains

G7 p.38:130mm

a. _____for up to

active

b. _____after the last dose and

several days

c. can inhibit even those_____ _____given as treatment.

transfused platelets

21. Complete the following concerning warfarin (Coumadin):

G7 p.39:42mm

a. Don’t start Coumadin until a_____ _____ _____ _____ has been achieved on heparin

therapeutic partial thromboplastin time (PTT)

b. to reduce the risk of _____ _____.

Coumadin necrosis

c. For the first 3 days of Coumadin therapy patients are actually _____;

hypercoagulable

d. therefore continue_____for a few_____.

heparin days

22. Possible heparin side effects include

G7 p.39:95mm

a. t_____

thrombosis

b. t_____

thrombocytopenia

c. These are due to:

     i. _____ in heparin-induced thrombosis

consumption

     ii. _____formed against a heparin–platelet protein complex

antibodies

d. In such cases of heparin-induced thrombocytopenia, treat with_____.

lepirudin (Refludan)

23. Low molecular weight heparin should have

G7 p.39:135mm

a. fewer_____complications

hemorrhagic

b. more predictable_____levels

plasma

c. less need to _____biologic activity

monitor

d. a longer_____ life

half

e. need for_____doses per day

fewer

f. a lower incidence of_____

thrombocytopenia

g. more effective in_____prophylaxis than warfarin

DVT

24. A serious side effect could be spinal _____ _____.

epidural hematoma

G7 p.39:170mm

25. Complete the following concerning coagulopathy:

G7 p.40:170mm

a. To reverse Coumadin anticoagulation in a patient who is at the usual therapeutic levels use_____.

2 to 3 units fresh frozen plasma

b. For severely prolonged coagulation use_____.

6 units fresh frozen plasma

c. To reverse PT from Coumadin use

     i. _____

vitamin Kaqua mephyton

     ii. administered by what route?

IM

     iii. Administration may be fatal if given_____.

intravenously

     iv. Why?

           h_____

hypotension

           a_____

anaphylaxis

26. Matching. Use the numbers of the listed terms to complete the following statements.

G7 p.41:20mm

prothrombin complex concentrate; protamine sulfate; vitamin K; AquaMEPHYTON

a. Coumadin is reversed by:

     i. p_____c_____c_____

     ii. v_____k_____

     iii. A_____

b. Heparin is reversed by p_____

     s_____

27. Complete the following concerning thromboembolism:

G7 p.42:35mm

a. Risk of embolism from calf deep-vein thrombosis (DVT) is_____%.

1%

b. Extends to proximal deep veins in_____%.

30 to 50%

c. Embolism from thigh veins is_____.

40 to 50%

d. Mortality of DVT of legs is_____.

9 to 50%

e. DVTs in NS (neurosurgical) patients occur in_____.

19 to 50%

28. Conditions that make NS patients prone to DVTs are

G7 p.42:50mm

Hint: clot

a. c_____ _____

concomitant sludging

b. l_____ – _____ _____

long-time immobility (i.e., bed rest, paralysis)

c. o_____ _____/d_____

operating room/dehydration

d. t_____ _____

thromboplastin release

29. The best prophylaxis against DVTs is

G7 p.42:110mm

a. PCBs is the abbreviation for_____ _____ _____

pneumatic compression boots

b. low_____ _____

dose heparin (5000 IU subcutaneous every 8 to 12 hours start first postop day)

30. Matching. One can diagnose DVT with the following tests. Match the finding with its appropriate diagnostic value.

G7 p.43:80mm

Diagnostic value:

gold standard; associated with PE and DVT; only 50% accurate; 99% specific

Clinical finding or procedure:

a. hot swollen tender calf with positive Homan sign

b. contrast venography

c. Doppler ultrasonography

d. D-dimer

31. What is the treatment of DVT?

G7 p.43:135mm

a. b_____ _____

bed rest

b. e_____ i_____ leg

elevate involved leg

c. h_____, L_____ or

heparin, Legoparin

d. L_____ plus

Lovenox

e. C_____

Coumadin

f. Consider G_____ f_____

Greenfield filter

g. a_____

ambulate

h. after_____ to_____ days

7 to 10

i. wear_____ – _____ _____

anti-embolic stockings

j. For how long ?_____

indefinitely

32. Extramedullary hematopoiesis can result in

G7 p.43:170mm

a. abnormal skull x-ray called_____ _____ _____

hair on end

b. spinal cord compression due to _____ _____ _____

vertebral body thickening

33. Extramedullary hematopoiesis can be treated with

G7 p.43:170mm

a. r_____ and/or

radiotherapy

b. s_____

surgery

34. True or False. Prostaglandins sensitize A-delta and C fibers.

true

G7 p. 44:140mm

35. True or False. Metastatic cancer pain can be desensitized by

G7 p.44:140mm

a. steroids

true

b. aspirin

true

c. nonsteroidal anti-inflammatory drugs (NSAIDs)

true

d. acetaminophen (Tylenol)

false

36. How do NSAIDs work?

G7 p.44:170mm

a. They inhibit_____

cyclooxygenase

b. which thereby interferes with the synthesis of p_____

prostaglandins

c. and t_____.

thromboxanes

d. This inhibits the function of_____

platelets

e. and prolongs_____ _____.

bleeding time

f. They may also injure_____ (_____).

kidneys (nephrotoxicity)

37. Complete the following concerning NSAIDs and platelet function:

G7 p.45:50mm

a. The NSAID that results in irreversible binding is_____.

aspirin

b. Which NSAID results in reversible inhibition of platelet function?

most NSAIDS

c. The NSAID that does not interfere with platelet function is_____.

Relafen (nabumetone)

38. List the dosages for the following substances:

G7 p.45:148mm

a. NSAIDs to use

     i. Naprosyn loading:_____ then_____ every_____ to_____ hours.

500 mg, then 250 mg every 6 to 8 hours

     ii. Motrin no loading: Start dose_____ to_____ mg then_____ times a day.

Start dose 400 to 800 mg, then 4 times a day

b. opioids to use (moderate to severe pain)

     i. Percodan no loading: Start dose_____ to_____ pill(s) every_____ to_____ hours.

1 to 2 pills every 3 to 4 hours

     ii. Vicodin no loading: Start dose _____ pill(s) every_____ hours. Limit_____ to_____ every_____ hours per day.

1 pill every 6 hours

8 pills every 24 hours

c. opioids to use (mild to moderate pain)

     i. codeine loading? Start dose_____ to_____ mg at _____hours, to_____ mg at_____ to_____ hours.

no loading 30 to 60 mg at 3 hours

60 mg at 3 to 5 hours

39. How much Tylenol is safe?

G7 p.46:145mm

a. comes in dosages of_____ or_____

650 or 1000 mg

b. safe up to_____ mg per day

4000

c. has a ceiling effect at_____ mg/day

1300

d. has hepatic toxicity above_____ mg/day

10,000

40. A serious side effect of Tylenol is_____ _____.

hepatic toxicity

G7 p.46:160mm

41. True or False. Regarding opioid analgesics:

G7 p.46:180mm

a. They are only indicated for the treatment of acute pain.

false

b. Tolerance develops with chronic use.

true

c. Potential for respiratory depression is limited.

false

d. Seizures are not a known adverse effect.

false

42. True or False. Regarding opioid analgesics:

G7 p.47:18mm

a. They have no ceiling effect.

true

b. With chronic use, tolerance develops.

true

c. Overdose is possible with severe respiratory depression.

true

d. Treatment of overdose includes administration of naloxone.

true

e. Flumazenil helps in treatment of overdose.

false (Flumazenil is useful in treatment of overdose from benzodiazepines not from opioids.)

43. True or False. Regarding narcotics:

G7 p.47:18mm

a. Some opioids may cause seizures.

true

b. Physical and psychological tolerance develops with chronic use.

true

c. There is a ceiling effect with increasing dosage.

false (There is no ceiling effect with opioids. Increasing dosage does increase effectiveness, but side effects may limit higher doses.)

d. Overdose can cause respiratory depression.

true

44. Complete the following mnemonic about opioids:

G7 p.47:28mm

a. o_____

overdose is possible

b. p_____

potential for respiratory depression

c. i_____

increase dosage = increase effect— no ceiling effect

d. o_____

small pupils—miosis—o

e. i_____

intoxication: treat with Narcan

f. d_____

develops tolerance with chronic use

45. To what type of opioid receptor subtype does tramadol (Ultram) bind?

μ (MU) opioid receptor

G7 p.47:103mm

46. Ultram acts centrally to inhibit reuptake of

G7 p.47:105mm

a. n_____ and

norepinephrine

b. s_____.

serotonin

47. True or False. OxyContin tablets should never be taken crushed, divided, or chewed.

true

G7 p.48:40mm

48. What is the intramuscular:per os (IM:PO) potency for morphine?

G7 p.49:20mm

a. single dose

1:6

b. chronic dosing

1:2 to 3

49. What metabolite of meperidine might cause delirium and seizures?

normeperidine

G7 p.49:22mm

50. True or False. When taken with monoamine oxidase inhibitors (MAOIs), meperidine may cause

G7 p.49:30mm

a. severe encephalopathy

true

b. death

true

51. Tricyclic antidepressants elevate levels of what endooenous analaesic?

endorphin

G7 p.548:150mm

52. Indicate the following adjuvant medications’ characteristic actions:

a. tricyclic

blocks serotonin uptake

G7 p.48:150mm

b. tryptophan

precursor of serotonin

G7 p.50:40mm

c. antihistamines

anxiolytic

G7 p.50:50mm

d. phenothiazine

tranquilizing

G7 p.50:75mm

53. What craniofacial pain syndromes are responsive to carbamazepine (Tegretol)?

G7 p.50:62mm

a. t_____ n_____

trigeminal neuralgia

b. g_____ n_____

glossopharyngeal neuralgia

c. p_____ -h_____ n_____

post-herpetic neuralgia

54. Matching. Match each adjuvant pain medication with each description.

G7 p.50:80mm

Description:

increases serotonin by blocking reuptake; increases serotonin by being a substrate for its production; anxiolytic and hypnotic, helps with nociceptive pain; tranquilizing, helpful with other adjuvants in neuropathic pain Pain medication:

a. tryptophan

Amino acid precursor for serotonin, a potentiator for analgesic effects of endorphin. Warning: Daily use depletes vitamin B₆—use multivitamins. Give 1.5 to 2 0 mg h.s.

b. phenothiazines

Example is fluphenazine (Prolixin). Give with tricyclic for neuropathic (diabetic) pain. May reduce seizure threshold.

c. tricyclic antidepressant

Elavil (75 mg q.d.), desipramine (10 to 25 mg q.d.), or doxepin (75 to 150 mg q.d.), more effective than norepinephrine reuptake blockers.

d. antihistamine

Histamine plays a role in nociception. Hydroxyzine 50 mg every a.m. and 100 mg every h.s.

55. True or False. Regarding antispasmodics/muscle relaxants:

G7 p.50:110mm

a. Robaxin (methocarbamol) is contraindicated in patients with peptic ulcer disease because of its aspirin content.

true

b. Parafon Forte (chlorzoxazone) should not be used because of its risk of fatal hepatotoxicity.

true

c. All of these act as central nervous system sedatives and have proven efficacious with acute low back problems.

false (Although they act centrally, their efficacy for acute low back problems is dubious.)

d. Soma (carisoprodol) may produce euphoria and has abuse potential.

true

e. Taken for “night cramps,” quinine sulfate is an abortifacient, can cause thrombotic thrombocytopenic purpura (TTP), and can also result in cinchonism.

true

56. True or False. Regarding benzodiazepines:

G7 p.51:92mm

a. Effective for treatment of anxiety and insomnia

true

b. Safe in the first trimester of pregnancy

false (Not safe in the first trimester of pregnancy; BZDs are contraindicated during first trimester—teratogenic.)

c. Shorter-acting agents are more likely to cause rebound depression or withdrawal symptoms.

true

d. Longer-acting agents result in cumulative sedation and impairment of psychomotor function.

true

57. True or False. The following group of benzodiazepines is more prone to cause rebound depression or withdrawal syndrome:

G7 p.51:100mm

a. long duration

false

b. intermediate duration

false

c. short duration

true

d. all of the above

false

e. none of the above

false

58. True or False. A contraindication to the use of benzodiazepines is

G7 p.51:115mm

a. second trimester of pregnancy

false

b. first trimester of pregnancy

true

c. third trimester of pregnancy

false

d. alcohol use

false (but adds no sedation)

e. hypoglycemia

false

59. True or False. Regarding midazolam (Versed):

G7 p.51:140mm

a. more potent than diazepam (Valium)

true

b. crosses blood-brain barrier

true

c. has good amnestic effect

true

d. has good anticonvulsant effect

true

e. is associated with respiratory arrest

true

60. You have been called in consultation to see a head-injured patient who is intubated, sedated, and paralyzed. How long must you wait to do your examination?

G7 p.51:150mm

a. if Pavulon has been used_____

about 60 minutes

b. if Norcuron has been used_____

about 60 minutes

c. if Versed has been used_____

about 2 hours

61. True or False. The following benzodiazepine has a greater amnestic effect:

G7 p.51:150mm

a. oxazepam

false

b. alprazolam

false

c. midazolam

true

d. temazepam

false

e. diazepam

false

62. True or False. The mechanism of action of flumazenil is to

G7 p.52:80mm

a. stimulate adenosine monophosphate (AMP)

false

b. inhibit AMP

false

c. hyperpolarize postganglionic neurons

false

d. competitively inhibit benzodiazepines at receptor sites

true

63. The correct order for the following oral benzodiazepines from long-acting to short-acting duration of action is:

G7 p.52:40mm

a. diazepam, flumazenil, alprazolam

false

b. flumazenil, alprazolam, diazepam

false

c. alprazolam, flumazenil, diazepam

false

d. alprazolam, diazepam, flumazenil

false

e. diazepam, alprazolam, flumazenil

true (Diazepam [Valium] is long acting. Alprazolam [Xanax] is intermediate acting. Flumazenil [Romazicon] is intermediate to short acting.)

G7 p.52:80mm

64. Complete the following statement about the previous answer. Therefore it is used for_____.

reversing benzodiazepine (BDZ) that had been used for conscious sedation or general anesthesia

G7 p.52:80mm

65. Unusual concerns with flumazenil are

G7 p.52:80mm

a. c_____ in p_____

contraindicated in pregnancy

b. works for only 10 to 60 minutes; therefore, r_____ may o_____

resedation may occur

66. True or False. Regarding flumazenil (Romazicon):

G7 p.52:80mm

a. resedation may occur if large amounts of benzodiazepines (BZDs) have been given

true

b. reversal of BZD-induced respiratory depression is partial or nil

true

c. duration of action is shorter than most BZDs

true

d. binds BZDs to stop/inhibit their action

false (Flumazenil competitively inhibits BZDs at receptor sites.)

e. may provoke panic attack

true

67. True or False. The recommended initial dose of flumazenil to reverse benzodiazepines used for conscious sedation or general anesthesia is

G7 p. 52:100mm

a. 5 mg IV over 15 seconds

false

b. 0.5 mg IV over 1 minute

false

c. 2 mg IV over 1 minute

false

d. 0.1 mg IV over 5 minutes

false

e. 0.2 mg IV over 15 seconds

true

68. True or False. How long before brain magnetic resonance imaging (MRI) is scheduled do you give chloral hydrate to a child?

G6 p.37:140mm

a. 5 minutes

false

b. 12 hours

false

c. 30 to 60 minutes

true

d. it is not relevant

false

e. 3 hours

false

69. True or False. The following drugs are used in the “DPT” lytic cocktail:

G6 p.37:160mm

a. meperidine, promethazine, chlorpromazine

true

meperidine (Demerol)

promethazine (Phenergan)

chlorpromazine (Thorazine)

b. meperidine, atenolol, flumazenil

false

c. propofol, promethazine, thiopental

false

d. haloperidol, propofol, methohexital

false

e. midazolam, atracurium, chlorpromazine

false

70. True or False. Examples of central nervous system (CNS) factors that increase the risk of stress ulcers are brain tumors and intracerebral hemorrhage (ICH) but not spinal cord injury.

false (Spinal cord injury is a CNS risk factor for stress ulcer also.)

G7 p.52:137mm

71. True or False. Extra CNS factors that increase the odds of stress ulcer are the following:

G7 p.52:143mm

a. burns covering > 25% of body surface area

true

b. hypotension

true

c. renal failure

true

d. coagulopathies

true

72. When is the peak time for acid and pepsin production after head injury?

3 to 5 days after injury

G7 p.52:155mm

73. There is a medication better than H2 antagonists to reduce incidence of stress ulcer.

G7 p.52:171mm

a. It is called_____.

sucralfate

b. The brand name is_____.

Carafate

74. Name the histamine (H2) antagonists you can prescribe.

G6 p.41:20mm

Hint: TAPPZ

a. T_____

Tagamet

b. A_____

Axid

c. P_____

Pepcid

d. Z_____

Zantac

75. Should prophylactic use of H2 blockers be used if steroids are given?

no—usually not warranted

G7 p.52:175mm